23376 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom Identification PEXh9TNO.
B%oa&a - ��a 23376
ante one:
AA L2 CITY OF CUPERTINO-BUILDING DIVISION 6
C2Vt
r' .Name:• , Lk.N. APPLICATION I PERMIT BUIL,DINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL I
A M/aghee Llc No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
❑ ❑ ®
LICENSED CONTRACTOR'S DECLARATION PFRArr IS5(IANCE El
I Mreby aftirmthat l am llcm@ed under ProvWmaof Chsper9(oammenc APPLIANCESRESIDEN IAL B DESCRIPTION
Ingwith SeGbn 7000)of DMdcr3ofthe Bun .,and PrefegonsCode,and
liloan bInfu— rand k,# PANELS , -ar/W �ay�#_AzA_
Lkxn Clara Lkro �S 9 l� V1/ '�`/
Date GHITECr C AMPS
A.,h ll CPS DECLARATION E A
g0u X00 Iundergand my phv.haB be uidnpubllc record. OVER 1000 AMI'B j�f�F��$).00R� $/SQ.Fr.
Ley EFaaad Prot(®bvl SIGNS ELECTRICAL �. V
<< OWNER-BUILDER DECLARATION
IMrehy.fi.m ti.m ..PtfromtheComd or'aLl n.elawf«the SVELIALCIRCUIT/M19C J jV1 E ,{a({
pp '� folbwing rtaam.Cietllan 7W 15,Bualna and Profmlov Codr.Mydty or
TEMP.METER OR POLE INST.
ITE el
Fy muntywhlch requlrerapermBtomrWrua,gter,ImprwgdemaWh,orreplr
5.� anygructum prbrtolbhin ha ,licenc purahert to the f«achpemdt a POWER DEVICES
01e•tlgvd W lament that M b Ikxn.ad pursuant to the provfrbv of the
OmContraori n
L1ceel<w(Chapter9(mmmd
enngwlthSnb7000
fn )ofDfvl-
OGt
gon3ofthe Bugnea.and Prdnebn CMe)arMW he la ammpt therafrom.M SWM'WNG POOL ELECTRIC VALUATION
S y.'.•..ti the basis for the alleged eaemptton. Any vldatbn of Section 70715 by any
a'c aPPllcent fora pemat@ubjet.the appilunt toot dull pevhydnot mom thin OUTLETSSWI7CFRSFIXfURFS
0v hundred doll,.(S5M.
�l,uowvro(th myempkryen B NEW R®FNIAL FIXLIR SQ,Ff. STORIES TYPECONSIRLCf1ON'
proprgy,or withw. .r.ffeb sob
i ��� mmpevatiae,wllldotlr woricand Negruturebmt Wended or olfcrtdfor
O vis Cx'e 7014,Bvlrim,and Profmbv Cade Ila Cordntors Llmnae Taw
SB whoclossuch toanowvr dpropertywM Wlmpoyce,psnikrmM1and OCC.GROUP RE£UMIS
whodoeamch workhlmae de throughhbowne.If,
protWMttitsuch
Improvements are not Intended orof(erM f«sale.If,however,the building or nypAL
Improvement beald wllhinorcyeardcanplelbn,theownerbuliderwl0��ve
t Men of proving that he did not build or lmprowe for purpxe dale.). QTY. PLUMBING PERMIT FEE
L u net of the property, en euv
llvely contracting with llmved FLOOD ZDTJE AI'N
contract.M covtrut the projet(See 70K Bualns and Profrrlov Code: PERMIT ISSUANCE
The Contractor'@ LI¢rae Law don not apply to an owner of property who AlTEt-DRAIN&VEJT-WAIIIt
build, or Imp.thereon,and who contracts for such pto)eev wIth
TTctor(d Banned nw puuto the Contratmi Lkxn,e law. BACK FLOW pROTBCT.DEVICE FEE SUMMARY
am vamp undo Sec B& P C for this rea,on
OUTSIDE FEES
DRAINS FLODR ROOF,AREA,ODND. SANITARY Y_ N
Owner Date RECET"
• WORKMAN COMPENSATION DECLARATION FD(TURFS PER TRAP SCHOOL TAX Y_ N_
'MI hereby aHlrm that 1 have a«rtl0ute d consent to or
@e141wre, a RFLF7Pf,/
1 ode of Worken'Compevatlenlvurann«aartlfled copythermffSec. GAS FA.SYST.QA.l INC40UTLEIS
3g00,Iab ) PARR ELF. Y_ N
rdlry.. C �/�D D.2.2— /.� ,- BUILDING
�
Cony GAS E.A.SYSTEM-0OVER BNLDINCDIVISIONFEES
GertWM copy b herebytumecity GREASE/INNUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Cert WM ropy b flied with the city IvpecHon dlWgon.
CERTIFICATE OF EKEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCESEMTR-SANITARYSIORM EA WEFT Date Recti tN
(I)orI.) rend not becompleted If the prrMt bf«arae hundred dollar
(fl Ic)«fes.) WATER HpATER w/v Piilnk= ENERGYFEE Y N
I certify cthat In the
any Pa fin anf the w«k anfor
as t di tiq@ p•mW b lwrM, 2.5
I atoll not amp re any person f any manner at m to become objet t.,he WATER S,STFM/TRFATINC
Workery Compensation Tawe of Glifoml..Date PAID
O Z NOTICEAppU.
NLW'RETIDEN77ALPLNB, SQFI'. Date Reoei IM
Z O NOTICE TO APPLICANT.aubjCAM:IL after rs'Conthla Coon predEaempbn,yw
ehouldbemma abjecttotMWorkers'
plyk t'Compe t. pro pW tithe labor TOTAL:
F N dcaredre meet farthwLLh comply with such provblav«this pemW @hallbe
� ] deemed revoked.W O CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby.mrm that there b a mmtroctlon lending agency for the perform. ELECTRIC FEE
7 = anm ofthe work forwhkhthb pend[h bvuM(Sec.3 ,CN.C.) TOTAL
V O Lander,Name IPLUMBING FEE O
LL H L<nder,Addree. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mrtlfythatl have read thiaappllotbnaM.laic thatthe above bdoroatim
(L bmmct. bti leeto complywo,andh mb muntytna repncu andgatelaws I'FRMIT ISSUANCE FEES. n�
} relating to building mntrutlon,and Mrtby autherize rtpresentativn of this Z '/
= city to enter upon the above.rentlared property for lmpetbn purpo,o. ALTFRORADDTOMICI-L Date RCfCI t71
V _ (we)agrec to vvr,hm
Mcrdfy an d keep harp ea,the Clty of Cupertlro
agalvt WbWtb,judgment.,teeaand upenan wh�mayb any wayacvur AIRHANDLINGUNIT(TO10,0)0CFM) SUBTOTAL:
agalvt vld Chy b mnaequenm d 1M granting d this permLL.
AIRHANDUNGUNTT(OVFRIO,010CFM) CONSTRUCTION TAX
sigwtvre o(AppOmnt/Contractor
Data D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCIASURE
Will lhe.ppBcant or futurebudding o pant mom or handle hazardous HEATINGUNITC101ME)0B'M DatC Recel tk
rvtedal a@ dMrcd by tie CLpertlno MuNctp.l Code,Chaper 9.17,and the aa
I ealth and Safety Cadt& flan 25532(a)7 HFATING UNIT(OVM IW,"BTU)
Yea; 4P O
—1W
IZr
the appllant rtWllding occupant use ry Flay Area
, VFNfIIATIONFAN SINGLE RFSID) ISSUANCE DATE
which trMt hanreent airrfct? nt,a,dMmd bytM Bay Arta Alr n
Qa Illy hlavgement LN. BORER-COMP PHP OR l00,IXU BTU) r A I D
Yea
No V
II read the hen natedab requirements under Chapter 495 of BORER-COMP(OVM I OO,ON BTU) �(T
tMCal0omlalde.khh Safely Code,Setbv25505,25533and255M.1 MAR 2G
uMer,taM that ifthabu Bdingdmrwtmrrantlyhavca tenant,that it is my NEW RESIDENTIAL MFGH. SQ.FT 1992
poralbdry to notify to part,d thenqulrement.which..be met
m Twuanm da Ifkap aloavpavy. CITY UY l:Ur� IBvv
r authcrleed.grnt Data ISSUED BY
TC3TAL
OFFICE COPY